Assignment: Present Concerns/CC
Name: M. O. Date: 05/21/18
Sex: Male Age/DOB/Place of Birth: 8 Y/O /04-20-2010/Miami, Florida
SUBJECTIVE
Historian: Dad
Present Concerns/CC:
“He hurt his right arm.”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)
Healthy, well-nourished child. Age appropriate communication and development. Patient is in the 2nd grade and doing well.
HPI: (must include all components)
8 year old male patient presenting with Dad with a complaint of injury to right arm. Dad states that patient fell today at school and landed on his right wrist. The patient reports that the extremity was iced at school. Dad denies administration of pain medication.
Medications: (List with reason for med )
None.
PMH:
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations: Updated
Family History ( Please identify all immediate family)
Father alive and well, mother alive and well.
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
He lives with both parents. Dad reports that he occasionally smokes cigars but not in the presence of patient. Patient is in the 2nd grade.
ROS
General
Denies, headache, chills, myalgia.
Cardiovascular
Denies chest pain/discomfort, heart problems
Skin
Denies rash or lesions.
Respiratory
Denies cough, difficulty breathing, wheezing.
Eyes
Denies discharge from eye, redness, or pain
Gastrointestinal
Denies abdominal pain, nausea, vomiting, change in appetite diarrhea, and constipation.
Ears
Denies pain or discharge
Genitourinary/Gynecological
Denies dysuria or changes in urinary pattern.
Nose/Mouth/Throat
Denies nasal congestion, nasal discharge or bleeding, mouth sores, mouth soreness, mouth pain, sore throat, or difficulty swallowing
Musculoskeletal
Reports injury and pain to left arm
Breast
Denies pain or tenderness
Neurological
Denies loss of consciousness, dizziness, headache, or alteration in mental status
Heme/Lymph/Endo
Denies weight loss, activity intolerance, heat or cold intolerance
Psychiatric
Denies depression, anxiety, or suicidal ideation
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight 30.3 kg Temp 98.9 F BP 97/59 mmHg
Height 50 in
BMI: 18.74
Pulse 100 x’ Resp 20 x’
Sp02
General Appearance and parent‐child interaction:
No acute distress, well-developed, well nourished, alert.
Skin
Skin pink, warm, and dry, no rashes or lesions noted.
HEENT
Head normocephalic, nasal mucosa normal, nares patent and clear, no eye discharge, normal conjunctiva bilaterally, moist mucus membranes, tonsils normal, no swelling noted.
Cardiovascular
S1S2 audible. Regular rate and rhythm. No murmurs.
Respiratory
Lungs clear, good air exchange, no wheezes or rales
Gastrointestinal
Abdomen round, soft, non-tender, and non-distended, normal bowel sounds, no organomegaly
Breast
Deferred
Genitourinary
Bladder is non-distended; no CVA tenderness, external and internal genitalia not examined.
Pediatric SOAP Note
Musculoskeletal
Limited range of motion to right wrist; no swelling, bruising, or obvious deformity noted, strong pulses noted.
Neurological
Alert, moves all extremities spontaneously
Psychiatric
Age appropriate development.
In-house Lab Tests – document tests (results or pending)
Right wrist x-ray – closed fracture at distal radius
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
Diagnosis
· 1. Closed fracture of distal end of right radius – S69.91XA
· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM, fracture indicated on x-ray
· Pertinent negatives – no obvious deformity, no swelling
· Rationale – Limited ROM following injury or trauma to the arm suggest possible fracture.
2. Other specified sprain of right wrist, initial encounter – S63.591A
· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM
· Pertinent negatives – no obvious deformity, no swelling
· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of sprain.
3. Dislocation of right wrist – M24.331
· Pertinent positives – reports recent injury to left arm, limited ROM to right wrist, pain with ROM
· Pertinent negatives – no obvious deformity, no swelling
· Rationale – Injury to the arm may result in a sprain, dislocation or fracture wrist. Absence of obvious deformity can is favorable of a sprain or dislocation; however, impaired ROM and confirmation of fracture via x-ray rules out diagnosis of dislocation.
·
· Primary diagnoses: Closed fracture of distal end of right radius – S69.91XA
PLAN including education
· Arm splinted with short arm Ortho-glass and ace wrap, sling applied for patient comfort. (Arora, Fichadia, Hartwig, & Kannikeswaran, 2014)
· Patient and dad instructed that patient avoid participation in PE until cleared by orthopedic, school note provided
· Administer Tylenol or Motrin every 4-6 hours as needed for pain.
· Follow-up with Orthopedics, copy of x-ray CD provided
·
References
Arora, R., Fichadia, U., Hartwig, E., & Kannikeswaran, N. (2014). Pediatric upper-extremity fractures. Pediatric Annals, 43(5), 196-204. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.3928/00904481-20140417-12
